Provider Demographics
NPI:1306970991
Name:MCMILLAN, REBECCA S (PT)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:S
Last Name:MCMILLAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N87W28518 SCOTT LN
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-9078
Mailing Address - Country:US
Mailing Address - Phone:414-217-5836
Mailing Address - Fax:
Practice Address - Street 1:2000 W BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-2787
Practice Address - Country:US
Practice Address - Phone:262-896-3446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2451-024251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40049400Medicaid
WI41203900Medicaid